2019 | AIDS Behav

Abstract:

People living with HIV who use illicit drugs continue to experience high rates of suboptimal treatment outcomes from antiretroviral therapy (ART). Although previous studies have identified important behavioural, social and structural barriers to ART adherence, the effects of patient-level factors have not been fully evaluated. Thus, we sought to investigate the prevalence and correlates of reporting ART was difficult to take among a cohort of illicit drug users in Vancouver, Canada. We accessed data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), an ongoing prospective cohort of HIV-positive illicit drug users linked to comprehensive HIV clinical monitoring records. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods in which individuals reported they found ART difficult to take. Between December 2005 and May 2014, 746 ART-exposed illicit drug users were recruited and contributed at least one study interview. Finding ART hard to take was reported by 209 (28.0%) participants at baseline, and 460 (61.7%) participants throughout the study period. Patients ingesting a greater daily pill count (adjusted odds ratio [AOR] = 1.12 per pill, 95% confidence interval [CI] 1.08-1.17) and experiencing barriers to healthcare (AOR = 1.64, 95% CI 1.34-2.01) were more likely to report difficulty taking ART. Patients less likely to report satisfaction with their HIV physician (AOR = 0.76, 95% CI 0.58-1.00) and achieve a non-detectable HIV viral load (AOR = 0.62, 95% CI 0.51-0.74) were more likely to report finding ART hard to take. In this community-recruited cohort of ART-exposed illicit drug users, a substantial proportion reported they found HIV treatment hard to take, which was clearly linked to higher dissatisfaction with healthcare experiences and, most importantly, a lower likelihood of experiencing optimal virologic outcomes. Our findings reveal a number of opportunities to improve HIV treatment experiences and outcomes for people who use illicit drugs, including the use of treatment regimens with lower pill burdens, as well as reducing barriers to healthcare access.

The recent BC-CfE study, published in BMC Public Health, adds to mounting evidence showing education’s important role in ensuring HIV prevention strategies are being broadly accessed. Previous studies, such as a BC-CfE study published in the journal AIDS and Behavior, found YGBM who had low levels of awareness of PrEP also had less access to condoms and preferred receptive anal sex. These factors increase overall likelihood of contracting HIV.

In order to encourage informed decisions about sexual health through education and training, MPowerment and Totally Outright are tailored to young people in the LGBTQ community. These youth interventions build capacity at an individual and community level (more information about these programs below).

“Our study shows that spaces run by and for youth may be important avenues for effectively implementing sexual education not discussed within the educational system. With this in mind, it is important to look at ways in which schools and community groups can bridge the generational gap in HIV knowledge through education,” said Kalysha Closson, PhD Student and lead author on the study. “It is critical to ensure all in the LGBTQ community are engaged and aware of the HIV prevention resources available to them today.”

Across Canada, GBM continue to be disproportionately affected by HIV. There is still work to be done to empower YGBM to make informed decisions around their sexual health and wellbeing. Health service delivery should be implemented in spaces that are friendly to youth and LGBTQ individuals, supported by training for health care providers to serve as allies. The delivery of age-appropriate sexual health care and education could help reduce HIV transmission among youth.

“Sexual health education in schools, grounded in lived experiences, has the potential to improve attitudes and awareness towards HIV prevention and treatment,” added Closson. “If we are to continue to keep up momentum in reducing HIV transmission rates, we need to provide opportunities for YGBM to learn about the numerous HIV prevention strategies available to them.”

Further Information

Mpowerment is an evidence-based behavioral intervention developed at the University of California, San Francisco, in the early 2000s. Since 2012, this program has been implemented in Vancouver by YouthCO, a youth-led community-organization that works to reduce the impact of HIV stigma. YouthCO has adapted Mpowerment by incorporating values of anti-oppression and engaging a broader group of youth affected by HIV. Mpowerment is an HIV leadership program for queer and trans youth in Vancouver, the Fraser Region and Prince George. More info: www.youthco.org/mpowerment

Totally Outright was launched in 2005 by the Community-Based Research Centre, a Vancouver-based non-profit organization working to strengthen health outcomes for gay and bisexual men. The program consists of a 40-hour leadership course to develop a corps of sex-savvy young gay and bisexual men. The aim is the program enable participants to educate others about sexual and mental health, HIV prevention (including seroadaptive strategies and harm reduction) and social justice issues. More info: https://checkhimout.ca/totally-outright

For the research, as part of the BC-CfE’s Momentum Health Study, active gay and bisexual men (GBM) were recruited from February 2012 to February 2015. Participants completed an in-person computer-assisted self-interview every six months, up to February 2017, with questions on sociodemographic factors, awareness of biomedical HIV prevention strategies, and an HIV treatment optimism-skepticism scale. Participants were asked if they had ever attended either of two Vancouver-based HIV-leadership programs designed for youth who are gay and bisexual men (YGBM). Of 698 GBM who enrolled in the longitudinal study, 36.8% were less than 30 years old at the first study visit. After controlling for gender identification, sexual orientation, HIV status, and income in the past six months, younger GBM (257 out of 698 respondents) had lower awareness of biomedical HIV prevention strategies and less optimism towards HIV treatments compared with older GBM (441 out of 698 respondents). Among younger GBM who attended HIV-leadership programs, there was a greater awareness of biomedical HIV prevention strategies and higher HIV treatment optimism was reported, compared with non-attendees.

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BC-CfE’s provincial BOOST Collaborative is following on the heels of the successful Vancouver-based BOOST Collaborative. BOOST is inspired by the made-in-BC Treatment as Prevention strategy and supports a Targeted Disease Elimination (TDE®) approach. This means using tools and strategies that have been proven through the work of the BC-CfE in curbing HIV transmissions. The TDE® strategy can address contagious diseases and diseases with a social contagion factor, such as substance use disorders. The first phase of the BOOST Collaborative doubled retention rates in the lifesaving opioid agonist treatment (OAT) for substance use disorders.

Among participating Vancouver Coastal Health (VCH) clinics, the number of individuals retained at three months made a significant jump — from three out of ten to seven out of ten.

The provincial expansion of BOOST has its eye on even greater goals, aiming to ensure that 95% of people with opioid use disorder have an active OAT prescription and 95% of those on OAT are retained at three months (or longer).

On February 14th, BOOST Collaborative teams from across the province—including Prince George, Kelowna, Chilliwack, Victoria, Nanaimo, Surrey and Vancouver’s Downtown Eastside—met for the first learning session in Vancouver. Teams have been tasked with creatively generating tactics and strategies, and even morale-boosting team names, in order to enhance their OAT treatment programs.

Dr. Laura Knebel was part of the pilot BOOST team at the Downtown Community Health Clinic (DCHC) in the heart of the Downtown Eastside. There was trepidation among her staff in the early days of the initiative. Quality improvement tasks, while only intended to take less than 10% of a clinic’s staff time, seemed overwhelming given competing demands.

Looking back on the year-long pilot, Dr. Knebel said the data collected for its quality improvements efforts helped pinpoint needs, while also showing encouraging signs of success. After finding that about half of DCHC clients did not have active OAT prescriptions, clinicians worked to identify a number of clients that could possibly be re-engaged in treatment. DCHC staff are now applying the learnings from BOOST to help clients with other conditions.

BOOST Lead and BC-CfE Senior Medical Director Dr. Rolando Barrios urged teams to take small steps wherever they saw opportunity, rather than waiting for reams of data. “You don’t need perfect data to act,” said Dr. Barrios.

Research supports the BOOST approach, showing the risk of morbidity and mortality decreases by 80% for individuals on effective OAT. Further, access to OAT has also been shown to drastically reduce levels of crime associated with drug use.

The concept of BOOST is reminiscent of the fable about the tiny mouse who pulled the thorn out of the elephant’s foot. The provincial BOOST Collaborative teams are taking on the work of implementing small programmatic changes to improve access to and sustainment in care—and these can have a big impact. This could include administrative tasks of improving intake forms or adding reminder calls to clients.

Provincial BOOST Collaborative

In 2010, the BC-CfE launched the STOP HIV/AIDS® Structured Learning Collaborative (the “Collaborative”) to improve the quality of HIV care and services, improve patient engagement & increase sustainment in care, and strengthen partnerships in care. As a result of the BC-CfE’s Collaborative, all participating teams saw improvements: namely, they implemented their learnings to deliver proactive and organized needs-based HIV care, with supports for patient self-management. The STOP HIV/AIDS® Collaborative provided the model for the BC-CfE’s BOOST Collaborative to work with provincial Health Authorities to help engage more individuals in treatment for opioid use disorder through opioid agonist treatment.

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February 6, 2019

On January 17th, the BC-CfE announced the launch of a provincewide initiative, supported by a funding grant from Health Canada's Substance Use and Addiction Program. The first-of-its-kind initiative based on the BC-CfE's world-renowned Treatment as Prevention (TasP) strategy to curb HIV and AIDS—will roll out across all BC regional health authorities in early 2019.

This initiative is building upon the successful foundation of a pilot project between the BC-CfE and Vancouver Coastal Health (VCH). The BOOST (Best Practices in Oral Opioid AgoniSt Therapy) Collaborative introduced a proactive model of treatment for opioid use disorder (OUD) to VCH clients at risk of overdose. Health care teams across Vancouver worked to implement system changes to effectively identify, diagnose and engage over 1,100 people in care for OUD—doubling those kept on lifesaving treatment at three months.

Through the Collaborative, health care teams created and implemented processes to better reach out to clients (for example, increasing follow-up calls and streamlining client intakes). These incremental changes are providing a path forward to help address the needs of those living with opioid use disorder. The initiative launches in the midst of the ongoing opioid drug overdose crisis, which the Government of BC declared a public emergency in 2016. There have been more than 3,800 confirmed deaths to illicit drug overdose in B.C. since January 1, 2016.

"The BC-CfE applied lessons from its proven effective HIV strategy, which drove a steady and consistent decline in HIV and AIDS, to address the urgent opioid overdose crisis affecting individuals and families provincewide," said Dr. Rolando Barrios, Senior Medical Director, BC-CfE. "Small-scale improvements in care, implemented through the work of VCH health care teams, created major, positive impacts on the lives of those affected by opioid use disorder. We can now apply these concepts to every region in BC."

Among VCH clinics participating in the BOOST Collaborative, the number of individuals retained in opioid agonist treatment (OAT) at the 90-day mark increased from three out of ten to seven out of ten—a very significant leap in improving access to regular, long-term care for opioid use disorder.

"I am extremely proud of the work of the VCH health care teams in successfully engaging with clients to improve their access to lifesaving opioid agonist therapy," said Dr. Patricia Daly, Chief Medical Health Officer and Vice President, Public Health, VCH. Dr. Daly is the Former Executive Lead of the Overdose Emergency Response Centre, established by the B.C. Government in 2017.

The BOOST Collaborative is based on an evidence-informed approach. Research shows that the biggest barriers to effective treatment for opioid use disorder are treatment access, dosage and retention.

A significant proportion of individuals struggling with opioid use disorder will reduce illicit opioid use and remain on treatment longer with appropriate doses of methadone, buprenorphine/naloxone or slow-release oral morphine (all categorized as OAT). The risk of morbidity and mortality decreases by 80% for individuals on effective OAT. Recent data from the BC Coroner's office found that, of the 1,800 deaths reviewed over a 19-month period (January 2016 to July 2017), none had buprenorphine present in their system.

Despite the known benefits of OAT, at baseline and before the launch of the Vancouver BOOST Collaborative, only 30-40% of individuals in Vancouver who started OAT remained on treatment at three months.

"Programs that help to meet clients where they are and address their needs effectively are fundamental to our progress against HIV with the Treatment as Prevention strategy," said Dr. Julio Montaner, Executive Director and Physician-in-Chief, BC-CfE. "The achievements of the BOOST Collaborative show the benefits in applying these principles to improving care and quality of life for individuals with opioid use disorder."

The provincial BOOST Collaborative aims to improve upon already impressive achievements of the VCH/BC-CfE pilot project, with the goals that 95% of clients on OAT will have an active OAT prescription and 95% of those clients with an active OAT prescription will be retained on therapy for longer than three months.

The newly launched BOOST Collaborative will be holding regular meetings among health care teams located at clinics across the province to share best practices. The BC-CfE will provide support as the teams work on identifying and addressing gaps in reaching clients within their own clinical settings

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Current data shows that only 3,500 individuals accessing care through Vancouver Coastal Health (VCH) clinics are on a therapeutic dose of Methadone or Suboxone, also called oral opioid agonist therapy (oOAT). However, approximately 9,000 clients are estimated to have an opioid use disorder and could benefit from the treatment. This means there are approximately 4,000 individuals who are not currently receiving oOAT, despite the evidence showing it could help curb opioid cravings and reduce risk of overdose. Further, the use of slow release oral morphine is indicated for roughly 5% of people with opioid use disorder, yet only approximately 0.5% of people are receiving this treatment.

The BOOST Collaborative aims to close these gaps, engaging and retaining more individuals with opioid use disorder into care. BOOST is the Best-practice in Oral Opioid agoniSt Therapy (BOOST) Collaborative, an initiative aiming for quality improvement in order to expand the reach, quality and effectiveness of oral opioid agonist therapy. Currently, BOOST is only being implemented with the Vancouver region. The initiative was developed and implemented by the BC-CfE in partnership with VCH.

A growing range of scientific and research evidence demonstrates that a significant proportion of individuals with opioid use disorder will respond to treatment with methadone or Suboxone. Opioid use disorder can be defined as a strong desire to use opioids, an increased tolerance to opioids, or experiencing withdrawal symptoms when not using opioids. Treatment success has been shown to be linked to shorter time to treatment from diagnosis and longer duration of treatment.

To learn more, we checked in with Laura Beamish, BC-CfE Quality Improvement Coordinator who has been highly involved with the launch of the BOOST Collaborative.

BC-CfE:How is the BOOST Collaborative working overall: Is it meeting the objectives you had hoped it would?

Laura Beamish, BC-CfE: Quality Improvement Coordinator: We are now entering our sixth month of the BOOST Collaborative and are very excited to see the progress made to date. One of the essential elements for successful quality improvement Collaboratives is identifying your population of focus—or the folks you are trying to improve care for. In our case, this means clients with opioid use disorder accessing services in Vancouver at clinics within VCH. This process involved working with teams to standardize clinical data entry, meaning the information collected to describe clients’ needs. This is the first step in easily and efficiently identifying clients with opioid use disorder within the electronic medical record.

The standardization process involves an incredible amount of work on the part of our frontline clinicians. As a result of these efforts so far, a greater number of individual records have been included in the system with an accurate diagnosis code: from around 600 clients to well over 3,000 in just five months. We continue to work with teams on standardizing their clinical data entry. Going forward, we hope to be able to share outcome measures based on interventions and care provided to clients, for example more precise information on metrics such as optimal dosing and retention.

We are also really pleased to see how far some teams have come in developing their quality improvement knowledge and skills. They have also come up with innovative approaches to applying this knowledge!

BC-CfE:Have you encountered any unanticipated barriers?

LB: In quality improvement we like to think of barriers as system opportunities. Implementing this project has allowed us to systematically identify common opportunities for improvement within the clinic teams, as well as across the health care system as a whole. This includes things like better linkages to local pharmacies and improved communication across programs.

BC-CfE:How do you feel about the results so far?

LB: I am excited to see the progress to date. While standardizing clinical data entry may not seem like a big step, it is critical to allow us to measure the hard work of our team as they evaluate changes implemented through BOOST. So far, this work has allowed physicians and allied health professionals to draw on the full capabilities of Profile EMR, which is the electronic clinical documentation system used by VCH. There have also been intangible and immeasurable positive results, such as relationship building and informal information sharing between providers. These are part of a hugely important piece to improving services across all of VCH programs.

BC-CfE:Are there any surprises?

LB: In my role as Quality Improvement Coordinator, I travel around the city (by bike) visiting all of our teams for one-on-one coaching. What continues to amaze me is the amount of compassion and care each and every one of the frontline staff brings to their daily work and to the BOOST Collaborative.

BC-CfE:Are you seeing a decent level of buy-in from all those involved?

LB: Yes, I would say that all of the teams involved believe in the value of this work and are excited. Where there was some hesitation, we shared information on exactly how the Collaborative is frontline-driven work to identify and close gaps in care. This helped to dispel any negative sentiments or myths about the program and allowed teams to feel ownership over the work. As teams continue to do this work and become more comfortable with quality improvement processes, they are becoming more innovative and excited to try different ideas.

BC-CfE:When will you be able to say this is in approach that will save lives?

LB: This is a difficult question to answer. If we can support improved retention on opioid agonist therapies, we can reduce the risk of overdose death for individuals who are at risk. It should be noted that currently BOOST is only capturing a segment of those being directly affected by the overdose crisis.

BC-CfE:To follow on your last answer, is BOOST being extended and why?

LB: Yes, a decision was made that a six-month extension of the BOOST Collaborative would allow us to make a maximum impact. The timing of BOOST paralleled to some degree the implementation of VCH’s Second Generation Strategy to form a new model of care in the Downtown East Side. Given the level of work needed to standardize clinical data entry and other adjustments taking shape, it was decided additional time would better allow all teams to become skilled with quality improvement methodology. The acquired learning can then be applied to other chronic illnesses such as hepatitis C or psychosis.

It is also possible that BOOST will expand to other communities and health authorities across B.C., bringing its potential benefits to a greater population of individuals.

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A new walk-in clinic for people with opioid addictions and other health issues including HIV and hepatitis C is opening in the Downtown Eastside.

The clinic, called Connections, will be accessible through a door on the alley at an expanded Hope to Health Research Centre at 625 Powell. People will be able to walk into the basement clinic and, without first seeing a doctor, get medication for HIV and hepatitis C, as well as methadone and suboxone for opioid addictions. Take home naxolone kits for treating overdoses from opioids such as fentanyl will also be available.

At Connections, where one wall of the clinic is a colourful mural by indigenous artist Jerry Whitehead, people can be referred to treatment, counselling and other health services.

Connections and an eye clinic are expected to open this spring.

The clinic is part of a bigger effort to take the successful techniques developed by the B.C. Centre for Excellence in HIV/AIDS in reducing the spread of HIV and treating AIDS and apply them to combating the current opioid crisis and a looming one in viral hepatitis.

“We are the grip of a public health crisis — more than 900 people lost their lives to illicit drug overdoses in 2016,” said Health Minister Terry Lake, during the official opening of the $2 million expansion of the Hope to Health Research Centre on Thursday.

He said research developed at the centre into addictions, hepatitis C and HIV has the potential to be put to use throughout the province. Dr. Julio Montaner, director of the B.C. Centre for Excellence in HIV/AIDs, said the centre’s success in dealing with HIV and AIDS allowed it to build a strong addiction medicine component.

“I would like to think we have the strength of the HIV program to support the efforts of our addiction program,” he said.

Montaner said the epidemic of viral hepatitis is “silent but powerful.” He said in North America, hepatitis C is the leading cause of infectious reportable death.

“We have a problem in front of us that is not as tangible as the addiction program but we know it is coming,” he said. “We have to get ready.”

Val Nicholson said 10 years ago, she was homeless, was living on the street and was an IV drug user. Now HIV positive, she said she was able to turn her life around and now helps people in the Downtown Eastside navigate the health system.

Nicholson, who spoke at the official opening, said given the successes B.C. has had in fighting against HIV and AIDS, she hopes the same thing can happen with hepatitis C and addictions.

“It is critical that we continue research in these areas,” she said. “Through research, we can better support individuals who are vulnerable. I really believe our voices are being heard.”

Some of the province’s most vulnerable people will benefit from research into HIV/AIDS, addiction and viral hepatitis that will be carried out at the world-class Hope to Health Research Centre following a successful expansion project supported in part through $2 million in government funding.

“Through the BC Centre for Excellence in HIV/AIDS, Vancouver has long been a leader in the research and treatment of HIV/AIDS,” said Health Minister Terry Lake. “This work has dramatically changed the lives of people around the world. And now, through Hope to Health Research Clinic, the BC-CfE will continue to strengthen and inform health strategies through its groundbreaking research on HIV/AIDS, viral hepatitis and addiction.”

Hope to Health is a BC Centre for Excellence in HIV/AIDS (BC-CfE) research clinic, which supports research to adapt, evaluate and expand Treatment as Prevention to other contagious diseases. Under the leadership of Dr. Julio Montaner, the clinic focuses on three pillars: HIV, addiction and viral hepatitis. The expanded facility at 625 Powell Street will open to clients in February 2017.

Hope to Health officially opened in June 2015 at 611 Powell Street in the Downtown Eastside. Following support from the world’s most competitive peer-reviewed granting agencies and the $2 million provided to St. Paul’s Foundation in 2015 to help the clinic expand, 625 Powell Street was further developed, adding an additional 186 square metres (20,000 square feet) to the existing facility.

“The BC-CfE has a long and successful history of addressing the needs of some of the most vulnerable populations in B.C.,” said BC-CfE director Dr. Julio Montaner. “We are grateful to the Province for the trust it has put in our team to continue our research towards developing innovative, evidence-based health policy strategies to improve the lives of British Columbians and people around the world.”

Research from Hope to Health is helping to inform the work of the BC Centre on Substance Use (BCCSU), which was established in part through a $5 million investment announced in September 2016. The BCCSU is working with addictions experts around the province on research, education and training, and treatment guidelines to make sure substance-use treatment in B.C. is effective and evidence-based.

“Addiction is one of the most prevalent and costly diseases in our society,” said Dr. Evan Wood, interim director, BC Centre on Substance Use, BC-CfE and medical director, Addictions Services, Vancouver Coastal Health and Providence Health Care. “The B.C. government’s investment in the establishment of the BC Centre on Substance Use and in the expansion of Hope to Health is a reflection of its continued commitment to improve the lives of some of the most vulnerable people living in B.C., and will also play an important role in addressing the overdose crisis over the long-term.”

The BC-CfE has partnered with Vancouver Coastal Health to establish a low-threshold addiction clinic and an eye clinic also located at 625 Powell Street to serve people in the Downtown Eastside. Both clinics are set to open this spring. The addiction clinic will have a pharmacy onsite and will be able to dispense medications for treating substance use disorders and other issues including HIV and hepatitis C. Referrals can be made for treatment beds, counselling and other services not offered at the clinic.

“Vancouver Coastal Health has worked successfully with the BC-CfE on numerous initiatives over the years, and we are pleased to expand that relationship with the opening of the addictions clinic, Connections, and our eye clinic,” said Dr. Patricia Daly, vice-president, public health and chief medical health officer, Vancouver Coastal Health. “We strongly believe that together we can make a significant difference in addressing the overlapping health challenges of HIV, addictions and viral hepatitis.”

The story of today's prescription opioid overdose crisis didn't start this year, or 10 years ago, or even 100 years ago. It starts with a plant—the opium poppy—that has been a part of human civilization for thousands of years.

Papaver somniforum—literally, 'sleep-bringing poppy'—is the scientific name for the type of poppy that produces opium, which humanity has relied on since before history was even a concept. Along with wheat, the opium poppy is one of the world's oldest cultivated plants, with some estimates suggesting that humans have been growing it for 10,000 years or more. It's been cultivated so widely we don't even know where it originates. Some think it's indigenous to the Eastern Mediterranean or the Swiss Alps, but frankly nobody really knows. What's clear, though, is that the relationship between humans and this strange and hardy plant (it can grow basically anywhere) goes beyond curiosity and into the realm of symbiosis.

There's a line from Lars Von Trier's Antichrist: "Nature is Satan's church," and perhaps there's no better example of the curious and uncanny relationships that form across species and time than the one between humans and the poppy. Opioids, the chemicals produced by papaver somniforum, somehow fit perfectly into the human body's opioid receptors, which are scattered throughout the brain, spinal cord, and digestive system, and this precise fit makes them exceptionally effective at suppressing pain. The geometry is so exact that some experts theorize that the opium plant and our neural architecture is the result of symbiotic co-evolution (some even think opium poppies shaped the development of human consciousness). The mystical pain-dampening plant on the one hand, the upright ape on the other.

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Surrey needs to cool the rhetoric and find a recovery-focused approach to its growing drug problem, addictions experts say.

The city is home to a growing level of drug abuse, mounting overdoses and frequent deaths, causing many to call for safe injection sites.

Last year, Surrey Fire Services responded to an average of 4.5 overdoses per day. That has climbed to about seven per day this year.

According to the B.C. Coroner’s Office, Surrey had 378 overdose fatalities in the last 10 years, with 71 of those occurring last year alone.

In the first six months of this year, there were 44 overdose fatalities in Surrey.

Since last year, there has been a huge spike in the amount of fentanyl mixed with street drugs.

Fentanyl is an often fatal opioid that’s 50 to 100 times more potent than morphine.

There has also been a emergence of a drug called W-18, of which very little is known. It is a painkiller (a suspected opioid) that is believed to be several times stronger than fentanyl.

Fraser Health is now saying communities need to be open to “safe consumption sites.”

The model many community members are looking at is Vancouver’s Insite – a safe injection site.

Insite, which opened in Vancouver 13 years ago, has been subject to more than 30 peer-reviewed studies, including those published in the New England Journal of Medicine in the U.S. and The Lancet, in Britain.

Critics say the studies have been widely criticized and that The Lancet took heat among academics for publishing one of them.

Most agree, however, the outcomes look promising.

There have been 263,713 visits to Insite by 6,532 individuals.

Of those, there were 1,418 overdoses at Insite, none of which were fatal.

However, some experts in addiction say the Insite model is not the answer for Surrey, or any other community facing the growing problem of addiction.

Former drug user, health centres speak in favour of safer sites

Ray Harrison has seen people shoot up using water from toilets and puddles.

He's pulled friends who were overdosing in the street to a phone booth to call 911, so they wouldn't be tracked by police.

Now Harrison — a former drug user himself who says he's been clean since the New Year's Day 2014 — says it's time for Ottawa to open a supervised injection site.

He believes they will help prevent people from spreading disease and give them a reason to access health care services, which could start them on a road to breaking their addictions.

"You need to be able to start somewhere and not necessarily when you hit rock bottom, when you get incarcerated," Harrison told CBC News ahead of tonight's Ottawa Board of Health meeting.

The city's medical officer of health, Dr. Isra Levy, is expected to make his case at that meeting for why Ottawa should have supervised injection sites, and why Ottawa Public Health should support agencies that propose to set them up.

Community health centres will be at tonight's Ottawa Board of Health meeting to offer Levy their full support, and Harrison is planning to be there, too.

"I think the safer injection site will save a lot of people, and the community, a lot of grief; along with the police [since] they're not having to chase these people down in somebody's backyard," Harrison said.

'The time is definitely now'

For many years Canadians heard only about the contentious Insite program in Vancouver.

That facility, which opened in 2003, has long been the only supervised injection site in the country — but as Levy notes in his report, a 2011 Supreme Court decision that granted Insite an exemption so its clients would not be charged for possessing illegal drugs has had a major impact across the country.